A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take?
Obtain filterless IV tubing.
Place the blood in a warmer for 1 hr.
Use a 24-gauge IV catheter.
Prime IV tubing with 0.9% sodium chloride.
The Correct Answer is D
Rationale:
A. Obtain filterless IV tubing: Blood transfusions require specialized IV tubing with an in-line filter to remove clots and debris. Using filterless tubing would increase the risk of transfusing particulate matter into the client’s bloodstream.
B. Place the blood in a warmer for 1 hr: Blood should only be warmed if specifically prescribed and done using an approved device immediately before administration. Prolonged warming increases the risk of bacterial growth and hemolysis.
C. Use a 24-gauge IV catheter: Packed RBCs should be administered through a larger-bore catheter (typically 18–20 gauge) to allow adequate flow and prevent hemolysis. A 24-gauge catheter is too small for efficient transfusion.
D. Prime IV tubing with 0.9% sodium chloride: Normal saline is the only compatible solution for priming and administering blood products. It prevents clotting and hemolysis while ensuring that the blood flows freely without interacting with other IV solutions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Playing with a jump rope: Jump rope requires advanced gross motor coordination and balance, which typically develops around age 4–5 years. A 30-month-old is not developmentally ready for this activity.
B. Playing with a large plastic truck: Toddlers around 2–3 years enjoy manipulating large toys such as trucks, cars, or blocks. This play supports fine and gross motor skills, hand-eye coordination, and imaginative exploration appropriate for their developmental stage.
C. Playing with dress-up clothes: Pretend or dress-up play becomes more common around age 3–4 years, as symbolic thinking and role-playing abilities develop. A 30-month-old may begin simple pretend play but usually engages in more concrete, manipulative play.
D. Playing with an imaginary friend: Engaging in complex imaginative play, such as interacting with an imaginary friend, usually emerges around age 3–4 years, reflecting more advanced cognitive and social development than expected at 30 months.
Correct Answer is D
Explanation
Rationale:
A. "I don't think you will benefit from reviewing your therapist's notes right now.": This statement dismisses the client’s request without addressing legal and policy guidelines regarding access to records. It also inappropriately assumes the client’s capacity to benefit from the information.
B. "Are you not happy with your treatment?": This redirects the conversation away from the request and implies dissatisfaction, which can create defensiveness. It does not provide the client with accurate information about their right to access medical records.
C. "Why are you interested in seeing your therapist's notes?": Asking “why” can sound confrontational and does not answer the client’s question. The focus should be on explaining what parts of the record can be shared, according to policy and law.
D. "We can provide a copy of your records, but the therapist's notes are not included.": Psychotherapy notes are excluded from standard medical record disclosures under HIPAA, as they are kept separate to protect sensitive details.
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